WEST VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG

1 west VIRGINIA GAS MILEAGE REIMBURSEMENT TRIP LOG Mail or Fax to: LogistiCare Claims Department 798 Park Avenue NW Norton, VA 24273 Fax #: 866-528-0462 Gas MILEAGE REIMBURSEMENT Billing Inquiries: 844-889-1942 DRIVER NAME: DRIVER PHONE #: DRIVER MAILING ADDRESS: CITY/STATE/ZIP: MEMBER ID #: I, _____, by submitting this driver log do affirmatively certify I have a current, valid and unrestricted west VIRGINIA driver s license; that the vehicle used to perform the services has passed an annual inspection by west VIRGINIA , and that the vehicle is currently and properly registered and insured pursuant to the laws and regulations of the state of west VIRGINIA .

2 IS TRIP A STANDING ORDER? Y N IF YES, CIRCLE THE DAYS TRAVELED WEEKLY: S M T W T F S Trip Date Trip/Job # Medical Provider Name & Phone # Physician/Clinician Signature* Total Miles Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: Name: Phone #: *Each date of service and each leg of trip must have a physician or clinician signature in order for REIMBURSEMENT to be approved. All MILEAGE REIMBURSEMENT trips are limited to 125 miles or less. I hereby certify the information contained herein is true, correct and accurate. Member Signature _____ Driver Signature_____